1. Status Asthmaticus
Management
Amina Al-Qaysi

3. Status Asthmaticus
• Acute exacerbation of asthma that is severe at
its onset or progresses rapidly despite
standard therapy, and remains unresponsive
to initial treatment with bronchodilators.
• Usually occur during sleep when airway
inflammation & hyperresponsiveness
are at their peak.

4. Management
1. Focused history
2. Clinical assessment
3. Risk factors for asthma morbidity & mortality
4. Treatment

5. 1. Focused History:
• Onset of current exacerbation
• Frequency & severity of daytime & night time
symptoms, activity limitation
• Frequency of rescue bronchodilator use
• Current medications, allergies
• Potential triggers
• Hx of systemic steroid courses, ER visits,
hospitalization, intubation, or life-threatening
episodes.

6. 2. Clinical Assessment:
• Vital signs
• Breathlessness, air movement, accessory
muscles use, retractions, anxiety, mental
status alteration
• Pulse oximetry
• Lung function (defer if Pt with moderate-
severe distress)

7. Manifestation Mild Moderate Severe
Alertness Normal Agitated May be drowsy
Dyspnea Absent, speaks
complete sentence
Speaks short phrases,
soft short cry
Speaks short phrases,
words
Pulsus paradoxus
(mmHg)
Less than 10 10-25 25-40
Accessory muscle use None Retractions,
sternocleidomastoid
Severe retractions,
nasal flaring
Skin color Good Pale Cyanotic
Auscultation End-expiratory
wheeze
Inspiratory, expiratory
wheeze
Quiet breath sounds
O2 saturation (%)
PCO2 (mm Hg)
PEFR (% of predicted
or best)
More than 95
Less than 42
More than 80
91-94
Less than 42
50-80
Less than 91
More than or equal 42
Less than 50

8. 3. Risk Factors for Asthma Morbidity & Mortality:
• Biologic:
Previous severe asthma exacerbation
Severe airflow obstruction
Hx of rapidly occurring attacks
Severe airway hyper-responsiveness
Increasing & large diurnal variation in peak flows
Decreased chemosensitivity and perception of
dyspnea
Poor response to systemic corticosteroid therapy
Low birth weight
Male gender, Non-white ethnicity

9. • Environmental:
Allergen exposure
Environmental tobacco smoke exposure
Air pollution exposure
Urban environment
• Economic & Psychological:
Poverty, Crowding, Mother younger than 20 yr
Mother with less than high school education
Inadequate medical care
Psychopathology in the parent or child
Family problems
Alcohol or substance abuse

10. 4. Treatment
• Oxygen: Mask or nasal cannula
• Monitor pulse oximetry
• Maintain oxygen saturation higher than 92%
• Cardio-respiratory monitoring

11. Drug MOA & Dosage
Inhaled short-acting B agonist Bronchodilation
Albuterol nebulizer solution (5
mg/ml concentrate; 2.5
mg/3ml, 1.25 mg/3ml, 0.63
mg/3ml)
Nebulizer: 0.15 mg/kg (minimum 2.5
mg)every 20 min for 3 doses as
needed, then 0.15-0.3 mg/kg up to 10
mg every 1-4 hr as needed, or up to
0.5 mg/kg/hr by continuous
nebulization
Albuterol MDI (90 Mg/puff)
Levalbuterol (Xopenex) nebulizer
solution (1.25 mg/0.5 ml concentrate,
0.31 mg/3ml, 0.63 mg/3ml, 1.25
mg/3ml)
2-8 puffs up to every20 min for 3 doses as
needed, then every 1-4 hr as needed
0.075 mg/kg (minimum 1.25 mg) every 20
min for 3 doses, then 0.075-0.15 mg/kg up to
5 mg every 1-4 hr as needed, or 0.25
mg/kg/hr by continuous nebulization

12. • Nebulizer: when given concentrated forms, dilute with
saline to 3 ml total nebulized volume
• For MDI use spacer/holding chamber
• During exacerbations, frequent or continuous doses can
cause pulmonary vasodilatation, V/Q mismatch, & hypoxia
• Levalbuterol 0.63 mg is equivalent to 1.25 mg of standard
albuterol for both efficacy & AE
• AE: palpitations, tachycardia, arrhythmias, tremor,
hypoxemia

13. Systemic Corticosteroids Anti-inflammatory
Prednisone
1, 2.5, 5, 10, 20, 50 mg tablets
Methyl-Prednisolone (Medrol)
2, 4, 8, 16, 24, 32 mg tablets
Prednisolone
5 mg tablets; 5 mg/5 ml and
15 mg/5 ml solution
Depo-Medrol (IM), Solu-
Medrol (IV)
0.5-1 mg/kg every 6-12 hr for
48 hr, then 1-2 mg/kg/day bid
(maximum 60 mg/day)
Short course burst for
exacerbation: 1-2 mg/kg/day
qd or bid for 3-7 days

14. • Systemic Corticosteroids
• If exposed to chicken pox or measles, consider
passive Ig prophylaxis. Also risk of complications
with herpes simplex & TB
• For daily dosing, 8 AM administration minimizes
adrenal suppression
• Children may benefit from tapering if course
exceeds 7 days

15. Anticholinergics Mucolytic/Bronchodilator
Ipratropium
Atrovent (nebulizer solution
0.5 mg/2.5 ml; MDI 18
Mg/inhalation)
Ipratropium with albuterol
DuoNeb nebulizer solution
(0.5 mg ipratropium + 2.5 mg
albuterol/3 ml vial)
Nebulizer :0.5 mg q6-8 hr
(tid-qid) as needed
MDI 2 puffs qid
1 vial by nebulizer qid

16. • Anticholinergics:
• Shouldn’t be used as first line therapy; added to
B2-agonists
• Nebulizer: may mix ipratropium with albuterol

17. Injectable Sympathomimitics Bronchodilator
Epinephrine
Adrenalin 1 mg/ml (1:1000)
EpiPen autoinjection device (0.3
mg; EpiPen Jr 0.15 mg)
Terutaline
Berthine 1mg/ml
SC or IM: 0.01 mg/kg
(maximum dose 0.5 mg);
may repeat after 15-30
min
Continuous IV infusion
(terbutaline only): 2-10
Mg/kg loading dose,
followed by 0.1-0.4
Mg/kg/min. Titrate in 0.1-
0.2 Mg/kg/min increment
every 30 min, depending
on clinical response

18. • Injectable Sympathomimitics
• For (extreme circumstances e.g. Impending respiratory
failure despite high dose inhaled SABA, respiratory failure)
• Terbutaline is B-agonist selective relative to epinephrine
• Monitoring with continuous infusion: cardiorespiratory,
pulse oximetry, BP, serum K
• AE: tremor, tachycardia, palpitations, arrhythmias, HTN,
headache, nervousness, nausea, vomiting, hypoxemia

21. Risk assessment for discharge
• Medical stability: symptoms improvement,
bronchodilator tt are at least 3 hr apart, normal
physical findings, PEF 70% of predicted or personal
best, O2 saturation 92% on room air
• Home supervision: capability to administer
intervention, and observe and respond to clinical
deterioration
• Asthma education

22. Respiratory Distress
Management

23. Respiratory Distress
• Clinical condition of increased Respiratory Rate &
use of accessory muscles of respiration.
• Can progress into respiratory failure (clinical
condition of inadequate oxygenation or
ventilation).
• It’s the primary diagnosis of 50% of patients
admitted to the paediatrics ICU

24. Causes
LUNG:
• Central airway obstruction
• Peripheral airway
obstruction
• Diffuse alveolar damage
RESPIRATORY PUMP:
• Chest wall deformity
• Brainstem
• Spinal cord
• neuromuscular

25. Management
• Emergency management: ABCDE.
• In patient is not in impending respiratory failure
then non-invasive methods of respiratory support
should be tried before initiating mechanical
ventilation
• Advantages of non-invasive ventilation:
1. Decreased risk of pneumonia.
2. No risk of developing ventilator-induced lung
injury.
3. Need for less overall sedation.

26. Oxygen Only Nasal cannula
Simple face mask
Non-rebreather
face mask
Deliver up to 4 L O2
Deliver up to 10 L O2
Deliver up to 15 L O2
Oxygen + non-invasive pressure
support
Nasal CPAP; effective
in neonates & patients
less than 8 Kg
BiPAP; in older
children or patients
more than 8 Kg
Can provide
continuous positive
airway pressure with a
backup rate
Can provide 2 levels of
support with
inspiratory positive
airway pressure &
expiratory positive
airway pressure
Non-Invasive Modes of Respiratory Support

27. • Goal of treatment is the restoration of adequate
gas exchange with a minimum of complications.
• Eliminate the initiating factors as quickly as
possible.
• Unfortunately, in these acute illnesses the
response to treatment is not immediate and
frequently the respiratory function must be
artificially supported.
• Hypoxemia is more dangerous than hypercarbia.
• Administration of supplemental oxygen is a safe
and wise precaution in all patients even in the
absence of initial evidence of hypoxemia.

28. • Mechanical ventilation is necessary in patients of
pneumonia with severe hypoxemia and
hypercarbia because even the most effective
antibiotic therapy require time (at least 24 hrs)
• Ventilatory support must be initiated in the
absence of alterations in arterial PCO2 when
dysfunction of other systems places gas exchange
at jeopardy (e.g. Cardiovascular shock).

29. References:
• Nelson Textbook of Pediatrics, 18th Edition,
Page 421-424, 966-969.
• Ski’s Essential Pediatrics, 2nd edition, Page 654-
659.